© Certification Application Guidelines

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Attachment 1 - Employment Verification Form, Page 2 of 2

Mobile: Email: Date of “Employee” appointment: “Employee” Job Title: Is the “Employee” presently employed with your Organisation or Company?

Yes No Please provide end date of employment contract:

Average hours per week ?

Total FTE equivalent of hours for term of employment? FTE are based on 38 hours per week over 48 weeks. Do you know of any information that may give rise to concern of the “Employee” that may disqualify the “Employee” as being a fit and proper person for recognition by the CMSA as a Certified Case Manager™? additional information or comments in relation to the “Employee” that you consider relevant for the attention of the CMSA. Declaration: Comments (optional): Please add any

Yes Please provide details: No

I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. I solemnly and sincerely declare that I have not omitted any information that may give rise to concerns by the Case Management Society of Australia (CMSA) as to the appropriateness of the “employee” receiving certification nor unduly challenge the veracity, integrity or fidelity of the Society, it’s members and the profession of Case Management.

Signature:

Date:

The Case Management Society of Australia (CMSA) Certification sets the benchmark of excellence in case management. Certified Practising Case Managers™ (CPCM) and Certified Case Managers (Non Practising)™ (CCMNP) adhere to the CMSA National Standards and National Code of Ethics for Case Management and are recognised for their advanced education, experience, knowledge, and skills by their colleagues, consumers and employers.